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On the Radar
Issue 220
27 April 2015
On the Radar is a summary of some of the recent publications in the areas of safety and quality in
health care. Inclusion in this document is not an endorsement or recommendation of any publication
or provider. Access to particular documents may depend on whether they are Open Access or not,
and/or your individual or institutional access to subscription sites/services. Material that may
require subscription is included as it is considered relevant.
On the Radar is available online, via email or as a PDF document from
http://www.safetyandquality.gov.au/publications-resources/on-the-radar/
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On the Radar
Editor: Dr Niall Johnson [email protected]
Contributors: Niall Johnson, Alice Bhasale
Reports
2014 National Healthcare Quality and Disparities Report
Agency for Healthcare Quality and Research
Rockville, MD: Agency for Healthcare Research and Quality; 2015.
URL
http://www.ahrq.gov/research/findings/nhqrdr/index.html
The (US) Agency for Healthcare Research and Quality (AHRQ) has released its
latest annual national (US) report on healthcare quality and disparities. These
reports measure trends in effectiveness of care, patient safety, timeliness of care,
patient centeredness, and efficiency of care. The report provides a snapshot of
health care quality and disparities based on trend analyses from 2000–2002 to
2011–2012. As most of the data predate the implementation of most of the changes
to health insurance stemming from the Affordable Care Act, the report also serves
as a baseline for measuring progress in future years.
Notes
AHRQ note that:
 US hospital care was safer in 2013 than in 2010, with 17 percent fewer
harms to patients and an estimated 1.3 million fewer hospital-acquired
conditions, 50,000 fewer deaths, and $12 billion in cost savings over three
years (2011, 2012, 2013). However, quality is still far from optimal, with
millions of patients harmed by the care they receive, and only 70 percent of
recommended care being delivered across a broad array of quality
measures.
On the Radar Issue 220
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A few disparities among racial groups for services such as childhood
vaccinations have been reduced to zero; however, much additional work
remains to address a broad range of other disparities affecting quality of
care.
Journal articles
Using clinical practice variations as a method for commissioners and clinicians to identify and
prioritise opportunities for disinvestment in health care: a cross-sectional study, systematic reviews
and qualitative study
Beynon C, Hollingworth W, Rooshenas L, Busby J, Hine C, Badrinath P, et al.
Health Services and Delivery Research. 2015; 3(13).
DOI
http://dx.doi.org/10.3310/hsdr03130
Detailed paper (full paper is 202 pages) discussing geographical variation in
procedure rates may be a marker of clinical uncertainty and could also be used by
to identify procedures that are potential candidates for disinvestment. Using
hospital episode statistics the study examined geographical variation in procedure
rates from 2007/8 to 2011/12 for 154 commonly used procedures in 151 English
Primary Care Trusts.
The authors report finding “a high degree of geographical variation in many
procedures that cannot be explained by proxies of clinical need. Many procedures
with the highest variability are not on the usual list of ‘low value’ procedures,
underlining the potential of this approach to identify emerging areas of
Notes
uncertainty.”
Their conclusions suggest that that this is an area with much utility but also
contention: “Policy-makers could use geographical variation as a starting point to
identify procedures where health technology reassessment or RCTs might be
needed to inform policy. Commissioners can use benchmarking to identify
procedures with high local use, possibly indicating overtreatment. However, coding
inconsistency and limited evidence are major barriers to achieving disinvestment
through benchmarking. Increased central support for commissioners to tackle
disinvestment is needed, including tools, accurate data and relevant evidence. Early
engagement with patients and clinicians is essential for successful local
disinvestment.”
For information on the Commission’s work on variation in health care, see
www.safetyandquality.gov.au/our-work/variation-in-health-care/
ASHP Guidelines on Preventing Medication Errors with Chemotherapy and Biotherapy
Goldspiel B, Hoffman JM, Griffith NL, Goodin S, DeChristoforo R, Montello CM, et al
American Journal of Health-System Pharmacy. 2015 April 15, 2015;72(8):e6-e35.
DOI
http://dx.doi.org/10.2146/sp150001
Many of the agents using in chemotherapy are highly toxic and need to be
administered with care and diligence. These guidelines have been developed by the
American Society of Health-Systems Pharmacists to help ensure best medication
Notes
safety practices are applied to the delivery of chemotherapy and biotherapy agents.
The recommendations include sets of specific actions for the health care system and
for frontline providers.
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On the Radar Issue 220
Polypharmacy among inpatients aged 70 years or older in Australia
Hubbard RE, Peel NM, Scott IA, Martin JH, Smith A, Pillans PI, et al.
Medical Journal of Australia. 2015;202(7):373-7.
DOI
http://dx.doi.org/10.5694/mja13.00172
Around 24% of patients aged 70 years or more in this study had 10 or more
medicines routinely prescribed medicines on hospital admission. Hubbard et al
compared the number of medicines recorded at hospital admission to the
number recorded at hospital discharge and found there was no change in either
the number or type of medicines prescribed to the patient. The authors infer
that treating clinicians could be doing more to rationalise the number of drugs
prescribed (deprescribing), whilst the older patient is in hospital. Use of
specific types of drugs that are potentially targets for deprescribing in older
Notes
people did not change (e.g. benzodiazepines, antipsychotics).
As noted, the study did not look into the appropriateness of medications on an
individual level, nor whether medicines reconciliation was formally undertaken
or not. Records were examined for the period 2005 to 2010. Medicines
reconciliation and development of a medication management plan are currently
developmental actions within the National Safety and Quality Health Service
Standards— it would be interesting to repeat the study in future to see whether
medicines reconciliation has any effect on polypharmacy rates.
For information on the National Safety and Quality Health Service Standards, see
http://www.safetyandquality.gov.au/our-work/accreditation-and-the-nsqhs-standards/
How to make medication error reporting systems work – Factors associated with their successful
development and implementation
Holmström A-R, Laaksonen R, Airaksinen M
Health Policy. 2015 [epub].
DOI
http://dx.doi.org/10.1016/j.healthpol.2015.03.002
Paper reporting on a study surveying the views of medication safety experts in 16
countries on factors associated with successful development and implementation of
medication error reporting (MER) systems in different healthcare settings. The
authors report:
 Several factors at national and local levels impact functionality of MER
systems (including awareness of deficiencies in medication safety at local
and national levels; gaining political will for the development and
implementation actions together with international and governmental
support; creating or reforming legislation and national regulations,
guidelines and strategies to support MER; allocation of adequate human and
Notes
financial resources; establishment of an organisation or centre to coordinate
and lead MER; and extending systems approach and safety culture to all
parts of the operational environment to facilitate openness on and learning
from medication errors).
 These factors should be considered when developing and implementing
MER systems.
 National recognition of deficiencies in medication safety needs to precede
actions.
 Political will and adequate resources are crucial.
On the Radar Issue 220
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The nurse's role in medication safety
Durham B
Nursing. 2015 Apr;45(4):1-4.
DOI
http://dx.doi.org/10.1097/01.NURSE.0000461850.24153.8b
This commentary piece discusses the vital role nurses play in the safe delivery of
medication. The authors briefly examines systems, human, and environmental
Notes
factors in medication administration errors and near misses before suggesting
changes in nursing practice that could make medication delivery safer.
For information on the Commission’s work on medication safety, see
www.safetyandquality.gov.au/our-work/medication-safety/
An enhanced recovery after surgery program for hip and knee arthroplasty
Christelis N, Wallace S, Sage CE, Babitu U, Liew S, Dugal J, et al.
Medical Journal of Australia. 2015;202(7):363-8.
DOI
http://dx.doi.org/10.5694/mja14.00601
This study evaluated a multi-modal program to enhance recovery and reduce
hospital stay after hip and knee replacement surgery, in three Victorian hospitals. A
pre-defined program of 16 items including peri- and post-operative analgesia, fluid
management, mobilisation and pre-admission assessment achieved a small but
Notes
statistically significant reduction in length of hospital stay. Hospital stay was
reduced by an average of 0.4 days overall and 0.8 days for knee surgery. There was
no significant difference for hip surgery patients. A greater proportion of patients
were discharged by day 3 after surgery compared with those receiving usual care.
Can staff and patient perspectives on hospital safety predict harm-free care? An analysis of staff
and patient survey data and routinely collected outcomes
Lawton R, O'Hara JK, Sheard L, Reynolds C, Cocks K, Armitage G, et al.
BMJ Quality & Safety. 2015 [epub].
DOI
http://dx.doi.org/10.1136/bmjqs-2014-003691
This British study compared patient and staff perceptions on safety (and with other
data). Surveying in 33 hospital wards across 3 acute hospital Trusts in the UK, staff
were asked to complete the four outcome measures of the Hospital Survey of
Patient Safety Culture, while patients were asked to complete the Patient Measure
of Safety and the ‘friends and family test’. These were collated with publicly
reported safety outcome data for ‘harm-free care’ on each ward. The authors report
Notes
that the while “views of patients and staff predict some overlapping variance in
patient safety outcomes, both also offer a unique perspective on patient safety,
contributing independently to the prediction of safety outcomes. These findings
suggest that feedback from patients about the safety of the care that they receive
can be used, in addition to data from staff to drive safety improvements in
healthcare.”
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On the Radar Issue 220
Communication of Vital Signs at Emergency Department Handoff: Opportunities for Improvement
Venkatesh AK, Curley D, Chang Y, Liu SW
Annals of Emergency Medicine. 2015.
DOI
http://dx.doi.org/10.1016/j.annemergmed.2015.02.025
Paper reporting an prospective observational study of emergency department (ED)
handovers/handoffs at a US urban academic hospital. From the observation of
1,163 patient handovers during 130 ED shift rounds it is reported that of “117
patients with episodes of hypotension and 156 patients with hypoxia, 66 (42%) and
Notes
116 (74%) were not communicated at rounds, respectively. One hundred sixty-six
handoffs (14%) included a vital sign communication error of omission.”
Omissions of significant information are a known issue with handover. A range of
tools or approaches of ‘flexible standardisation’ to assist clinicians in identifying
the necessary information for handover in various contexts have been developed.
For information on the Commission’s work on clinical communications, including clinical
handover, see www.safetyandquality.gov.au/our-work/clinical-communications/
International Journal for Quality in Health Care
Vol. 27, No. 2, April 2015
URL
http://intqhc.oxfordjournals.org/content/27/2?etoc
A new issue of the International Journal for Quality in Health Care has been
published. Many of the papers in this issue have been referred to in previous
editions of On the Radar (when they released online). Articles in this issue of the
International Journal for Quality in Health Care include:
 Editor's choice: Quality of care in primary health care settings in the
Eastern Mediterranean region: a systematic review of the literature (Shadi
Saleh, Mohamad Alameddine, Yara Mourad, and Nabil Natafgi)
 Interventions to improve cultural competency in health care for
Indigenous peoples of Australia, New Zealand, Canada and the USA: a
systematic review (Anton Clifford, Janya McCalman, Roxanne Bainbridge,
and Komla Tsey)
 Editor's choice: Observation of handover process in an intensive care unit
(ICU): barriers and quality improvement strategy (Yanika Kowitlawakul,
Benjamin S H Leong, Adela Lua, Rana Aroos, Jie Jun Wong, Nicola Koh,
Nicholette Goh, Kay Choong See, Jason Phua, and A Mukhopadhyay)
Notes
 A feasibility study of the provision of a personalized interdisciplinary
audiovisual summary to facilitate care transfer care at hospital discharge:
Care Transfer Video (CareTV) (Harvey H. Newnham, Harry H. Gibbs,
Edward S. Ritchie, Karen I. Hitchcock, Vathy Nagalingam, Andrew Hoiles,
Ed Wallace, Elizabeth Georgeson, and Sara Holton)
 Developing performance indicators for clinical governance in
dimensions of risk management and clinical effectiveness (Saber AzamiAghdash, Jafar Sadegh Tabrizi, Homayoun Sadeghi-Bazargani, Sakineh
Hajebrahimi, and Mohammad Naghavi-Behzad)
 Joint influence of patient-assessed chronic illness care and patient
activation on glycaemic control in type 2 diabetes (Eindra Aung, Maria
Donald, Gail M Williams, Joseph R Coll, and Suhail A R Doi)
 Quality of care for hip and knee osteoarthritis at family medicine clinics:
lessons from Mexico (Svetlana V Doubova and Ricardo Perez-Cuevas)
On the Radar Issue 220
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Results of a fast-track referral system for urgent outpatient hepatology
visits (Martina Milana, Francesco Santopaolo, Ilaria Lenci, Simona
Francioso, and Leonardo Baiocchi)
Towards actionable international comparisons of health system
performance: expert revision of the OECD framework and quality
indicators (F Carinci, K Van Gool, . Mainz, J Veillard, E C Pichora, J M
Januel, I Arispe, S M Kim, NS Klazinga, on Behalf of The OECD Health
Care Quality Indicators Expert Group)
Interoperability after deployment: persistent challenges and regional
strategies in Denmark ( Patrick Kierkegaard)
Appropriateness of requests for human serum albumin at the University
Hospital of Palermo, Italy: a prospective study (Alessandra Casuccio,
Eliana Nalbone, Palmira Immordino, Concetta La Seta, Paola Sanfilippo,
Antonino Tuttolomondo, and Francesco Vitale)
Disclaimer
On the Radar is an information resource of the Australian Commission on Safety and Quality in
Health Care. The Commission is not responsible for the content of, nor does it endorse, any articles
or sites listed. The Commission accepts no liability for the information or advice provided by these
external links. Links are provided on the basis that users make their own decisions about the
accuracy, currency and reliability of the information contained therein. Any opinions expressed are
not necessarily those of the Australian Commission on Safety and Quality in Health Care.
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On the Radar Issue 220